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Medication Error Quality Initiative (MEQI)
October 1, 2011 to September 30, 2012
ANNUAL REPORT
2012
Medication Error Quality Initiative
Improving Medication Safety in
North Carolina Nursing Homes
MEQRX I
2
Medication Error Quality Initiative (MEQI)
Cecil G. Sheps Center for Health Services Research
The University of North Carolina at Chapel Hill
CB #7590, 725 Martin Luther King Jr. Blvd.
Chapel Hill, NC 27599-7590
For more information contact:
Charlotte Williams, Project Manager
Phone: 919-966-7927
Email: meqi@shepscenter.unc.edu
PROJECT WEBSITE:
htp://www.shepscenter.unc.edu/meqi
This report is produced by the Cecil G. Sheps Center for Health Services Research (Sheps Center)
at the University of North Carolina at Chapel Hill for the North Carolina Department of Health
and Human Services, Division of Health Service Regulation.
Funded by:
The North Carolina Department of Health and Human Services, Contract #00022236
Authors:
Charlote E. Williams, MPH1, Sandra B. Greene, DrPH1; Richard A. Hansen, PhD2; Stephanie
Pierson, MSHI1; and Rishi Desai, MS 4
1 Cecil G. Sheps Center for Health Services Research at the University of North Carolina at
Chapel Hill, Chapel Hill, NC
2 Harrison School of Pharmacy, Auburn University, Auburn, Alabama
4 UNC Eschelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel
Hill, NC.
Suggested Citation: Williams CE, Greene SB, Hansen RA , Pierson S, and Desai, R. NC Nursing
Home Medication Error Quality Initiative (MEQI), Annual Report FY2012, October 1, 2011 to
September 30, 2012. Chapel Hill, NC. The Cecil G. Sheps Center for Health Services Research at
the University of North Carolina at Chapel Hill.
Medication Error Quality Initiative
Improving Medication Safety in
North Carolina Nursing Homes
MEQRX I
3
Table of Contents
(Page 4) MEQI Project
(Page 4) Highlights
(Page 4) Anti-Coagulation Research
(Page 5) Therapeutic Class Research
(Page 5) Analgesics Research
(Page 5) FY 2012 Data Summary
(Page 6) Table: 2009-2012 Data Summary
(Page 6) Graph : Errors per Nursing Home, FY 2012
(Page 7) Patient Outcomes
(Page 7) Table: Patient Outcomes: Definition of Minor/Serious
(Page 7) Table: Patient Outcomes FY 2012
(Page 8) Patient Characteristics
(Page 9) Table: Patient Characteristics FY 2012
(Page 10) Types of Error
(Page 10) Table: Type of Error FY2012
(Page 11) Table Medications Involved in Error FY2012
(Page 12) Medications Involved in Error
(Page 12) Therapeutic Class
(Page 12) Table: Therapeutic Class Involved in Error FY2012
(Page 13) Efects of Error on Patients
(Page 13) Table: Efects of Error FY2012
(Page 13) Cause of Error
(Page 14) Table: Cause of Error FY2012
(Page 14) Phase Where Errors Occur
(Page 15) Table: Phase of Error Occurrence FY2012
(Page 15) Graph: Phase of Error Occurrence Chart FY2012
(Page 15) Graph: Primary Personnel FY2012
(Page 15) Personnel Involved in Error
(Page 15) Graph: Errors by Works Shift, FY 2012
(Page 16) Table: Personnel, FY2012
(Page 17) Work shift
(Page 17 Table: Work Shift of Error Occurrence, FY2012
(Page 18) Conclusion
Notes on Tables and Graphs
• Patient Characteristics Table - errors in category one (circumstances) do not include patient information as no patient was
involved.
• See the Patient Outcome section in the narrative for a definition of Minor and Serious Outcomes. Some national studies choose
not to use patient outcome 4 as a serious error. These errors have been intentionally included in MEQI Serious Errors because any
error with an efect that requires monitoring and/or intervention to preclude harm should be regarded as a serious error.
• Serious Outcomes are highlighted in red within the chart in some tables if they are double the average number of serious errors.
4
MEQI FY2012
The MEQI Project
The Medication Error Quality Initiative, or MEQI, is a North Carolina nursing home medication error
reporting system, as required by NC Senate Bill 1016 (2003). All state licensed nursing homes have
reported medication errors since January 2004, initially using an online annual summary system.
Beginning in 2006, nursing homes transitioned to an improved online system where errors are entered
individually as they occur throughout the year. Since 2009 all nursing homes have used the new system.
398 nursing homes currently are participating in reporting. Due to a lack of funding, this will be the final
year of the MEQI Project. The section of the law which requires reporting is intended to be repealed.
Though reporting is ending, nine years of focus and atention to medication errors has brought a new
awareness of patient safety to NC nursing homes.
Highlights
• A reduction in reporting of pharmacy dispensing errors has continued this year.
• Warfarin and insulin continue to be involved in large numbers of errors, many of those with
serious outcomes.
• Warfarin errors are likely to be caused by transcription errors, communication problems,
inadequate information, and shift change. These areas should be addressed if warfarin
errors are common in your facility.
• Drugs in these classes—anxiolytics/sedatives/hypnotics, anti-diabetic agents, anticoagulants,
anticonvulsants, and ophthalmic preparations—are more likely to be reported in errors after
considering how often the various drug classes are used by nursing home residents.
• Medication errors still occur commonly during transitions from hospital, home or other
facility. Atention to this area has reduced serious errors, but errors still commonly occur.
Anti - Coagulation Research
MEQI staf has completed an analysis of the anticoagulant medication errors occurring over a two year
period. Anticoagulant medications include warfarin, enoxaparin, and heparin. Warfarin is the most
common drug involved in error in 2012. Research shows a relationship between this type of medication
error and patient harm, and identifies areas nursing homes could target for preventing anticoagulant
errors. Of 32,176 medication error incidents reported over a 2-year period, 1,623 (5%) were anticoagulant
medication errors and 2% of these errors (n=29) resulted in patient harm. Anticoagulant medication
errors had higher odds of patient harm when compared with other errors (OR=1.79, 95% CI: 1.20-
2.66), and anticoagulant errors were significantly more likely than other drug errors to be caused by
transcription error, communication problems, inadequate information, and shift change (p<0.05 for all).
Desai, R., Williams, C.E., Greene S.B., Pierson S. and Hansen R.A. “Anticoagulant medication errors in
nursing homes: characters, causes, outcomes and association with patient harm”, Journal of Healthcare
Risk Management, (accepted for publication November 2012)
5
Therapeutic Class Research
In another analysis, MEQI staf identified 10 drug classes most frequently involved in medication errors.
Patient characteristics and impact of these medication errors on patients were further examined.
The MEQI data were combined with data from the 2004 National Nursing Home Survey (NNHS) to
compare medication usage to medication error occurrence. There were 32,176 individual medication
errors reported to MEQI in years 2010-11. The 10 drug classes most commonly involved in medication
errors were analgesics (12.27%), anxiolytics/sedative/hypnotics (8.39%), anti-diabetic agents (5.86%),
anticoagulants (5.04%), anticonvulsants (4.05%), antidepressants (4.05%), laxatives (3.13%), ophthalmic
preparations (2.77%), antipsychotics (2.47%) and diuretics (2.34%). The analysis suggests that certain
drug classes are more likely to be involved in medication errors in NH patients regardless of the extent of
their use. The drug classes frequently and disproportionately involved in errors in nursing homes include
anxiolytics/sedatives/hypnotics, anti-diabetic agents, anticoagulants, anticonvulsants, and ophthalmic
preparations. Beter understanding of the causes and prevention strategies to reduce these errors may
improve NH patient safety.
Desai, R., Williams, C.E., Greene S.B., Pierson S., Caprio A. and Hansen R.A. “Exploratory evaluation of
medication classes most commonly involved in nursing home errors”, Journal of the American Medical
Directors Association, (accepted for publication November 2012)
Analgesics Research
MEQI staf also is in the process of conducting research focused on analgesic medication errors and their
association with patient harm. A total of 32,176 individual medication error incidents were reported over
a 2-year period in North Carolina nursing homes, 12.3% (n=3,949) of which were analgesic medication
errors. Of these analgesic medication errors, opioid and non-opioid analgesics were involved in 3,105
and 844 errors respectively. The initial analysis indicates that opioid errors are more likely to be wrong
drug errors, wrong dose errors, and administration errors compared to non-opioid errors (p<0.0001 for
all comparisons), and had an increased likelihood of patient harm compared with non-opioid analgesics.
FY 2012 Data Summary
This report provides data submited during fiscal year 2012 (October 1, 2011 to September 30, 2012).
For FY 2012, all North Carolina nursing homes submited medication error incidents and also completed
a year-end form to verify that submission was complete. Although it is mandatory to report all errors
and potential errors, the completeness of reporting varies. The number of errors reported by individual
facilities in FY 2011 ranges from 0 to 1559, a range which is not correlated with the size of the facility.
Sites are also asked to report if any medication-related liability claims had been filed against their facility
during the year. One nursing home reported 2 medication-related liability claims in FY 2012.
A total of 14,526 error incidents were reported in FY 2012 by 398 nursing homes. The mean number of
error incidents per nursing home was 36, with an average of 30 errors per 100 beds. The median number
of errors was 19 per facility. This is a decrease of 2,465 reported errors from the FY2011 report (a 14.5
% decrease) for the same number of facilities. This decrease appears to be almost entirely atributed to
two high volume reporting sites. The cause of the drop in reporting volume is unknown, though it could
be related to turnover in a leadership position (director of nursing or administrator), or a change in how
these facilities identify or report errors. The reduction is noticed primarily in outcome Category 2 (error
occurred, but did not reach the patient) and in the ‘wrong documentation’ type of error.
6
Of the 14,526 errors, 4,988 (34.3%) were repeated at least once and, for this year’s data, there was
an average of 12.3 repeats before the error was discovered. There were a total of 61,730 total repeat
occurrences of errors including the original error, which is an average of 155 repeat errors per nursing
home. An example of a repeated error would be a situation where a physician orders that a drug be
discontinued, but this discontinuation does not get recorded in the Medication Administration Record
(MAR), resulting in the drug being administered to the resident for five additional days. This would be
reported by a nursing home as one error incident, but the form would indicate that there were five
repeat occurrences of the error.
MEQI Reports
Error Incidents per Nursing Home
FY 2012
Number of Nursing Homes
0
10
20
30
40
50
60
70
80
90
100
110
Error Incidents Per Nursing Home
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 100+
MEQI Reports
Summary Data
FY 2012
Fiscal Year
2012 2011 2010 2009
Number of nursing homes 398 398 397 395
Total number of error incidents 14,526 16,974 15,202 14,395
Number of error incidents with 1+
repeats
4,988 5,270 5,456 5,064
Total errors including repeats 61,730 67,941 66,256 59,558
Mean error incidents 36 43 38 36
Median error incidents 19 21 20 22
Incidents per 100 beds 30 35 32 31
7
The data summary table shows results for the last four years, FY 2009 – FY 2012. A graph is also provided
that shows the numbers of error incidents per nursing homes. This graph shows that about half of the
nursing homes reported between 0 and 19 errors in FY 2011. Another 25% of homes reported between
20 and 39 errors, and the last 25% reported more than 40 errors. Accounting for nursing home bed
size has very litle impact on these results. Though
some variation of errors might be accounted for
by the quality of the nursing home, this large
variation in errors suggests that all nursing homes
may not use the same standards for what kinds of
errors are reported.
Patient Outcomes
All errors are categorized by those who submit the
error into one of nine patient outcomes. The nine
outcomes have then been further categorized by
MEQI into a minor or serious outcome category.
The minor errors are those where no patient was
involved, the error does not reach the patient, or
where the error reached the patient but there
was no harm or efects (i.e. dose omission with no
physical efects). Those errors placed in the serious
category are those where ongoing monitoring or
intervention were needed, or an error where the
patient was harmed temporarily or permanently.
Patient Outcomes: Definition of Minor/Serious
MINOR
ERROR
OUTCOMES
1 Capacity to cause error; no patient involved
2 Error occurred; but did not reach the patient
3 Error occurred and reached the patient, but did
not cause harm (dose omission with no efecte
should be included here)
SERIOUS
ERROR
OUTCOMES
4 Error occurred and reached the patient and
required monitoring and/or intervention to
preclude harm
5 Error occurred and reached the patient and
resulted in temporary patient harm
6 Error occurred and reached the patient and
resulted in temporary harm, requiring a trip to
Emergency Department
7 Error Occurred and reached the patient and
contribued to permanent patient harm
8 Error occurred and reached the pateint and
resulted in intervention necessary to sustain life
9 Error occurred and reached the patient and
contributed to the patient’s death
MEQI REPORTS
Patient Outcomes
FY 2012
Error
Incidents
% Repeat
Errors
%
All Errors 14,526 100.0 61,730 100.0
Patient Outcome
1=Capacity to cause error 512 3.5 1,910 3.1
2=Did not reach patient 674 4.6 1,761 2.9
3=Reached the patient but did not cause any
harm
12,026 82.8 52,216 84.6
4=Required monitoring/intervention to
preclude harm
1,193 8.2 5,295 8.6
5=Temporary harm to patient 93 0.6 346 0.6
6=Temporary harm with trip to ER 28 0.2 202 0.3
7=Permanent patient harm 0 0.0 0 0.0
8=Intervention necessary to sustain life 0 0.0 0 0.0
9=Patient death 0 0.0 0 0.0
8
For FY 2012, 91.0% of errors were in the minor outcome categories and 9.0% were in the serious outcome
categories. This is a slight increase in the percentage of serious errors from FY2011, but this is most likely
related to the reduction of non-serious errors reported by two high volume nursing homes. Of the 91.0%
minor errors, 8.1% were either a situation where there was a capacity for error, or the error was stopped
before it reached the patient and 82.8% were errors that reached the patient, but caused no harm. Of
the 9.0% serious outcome errors, nearly all were errors that required monitoring and/or intervention
to preclude harm (8.2% of total). Only 121 errors (0.8%) lead to temporary harm to the patient (with or
without ED visit). In 2012 there were no incidents reported in the three most serious patient outcome
categories (permanent patient harm, intervention necessary to sustain life or death).
Patient Characteristics
Errors by Age Group and Gender
By age group, 15.5% of NC nursing home patients afected by medication errors this year are under 65
(2,246 errors), 19.3% between ages 65-74 (2,808 errors), 29.5% between the ages of 75-84 (4,287), and
32.2% 85 years or older (4,673). The age of patient does not appear to be related to the seriousness of
the error. However, based on the national nursing home survey from 2004, it would be expected that
about 12% of residents are younger than 65 years of age, 12% between 65-74, 32% between 75-84, and
45% over 85. It would appear that errors are proportionally more likely to afect the younger nursing
home population (under 74) more often than the over 85 population; however this does not take into
account the number of medications and doses in each age group. Further research is needed in this area.
Regarding gender, 68.2% of the errors reported were for patients who were female and 28.2% were male,
which is similar to the gender distribution of the national nursing home population of 71.2% female and
28.8% male (National Nursing Home Study 2004).
Resident’s Ability to Direct Their Own Care
Nursing home staf members who record errors are asked to identify whether the patient is able or
unable to direct their own care. 27.9 % of errors involve residents identified as able to direct their own
care, and 65.4% involve residents who are unable to direct their own care.
Errors during Transitions of Care
Whether the error occurred while the patient was transitioning into the nursing home from their home,
hospital or another facility was also recorded, and such a transition is noted in 12.2% of error incidents.
A total of 1,779 errors occurred in transition, 68 from home (0.5%), and 1,658 from hospital (11.4%) and
53 from another facility (0.4%). Over time we have seen a reduction in the number of serious errors in
transition from both home and hospital–most likely due to the national focus on this topic and the new
emphasis on reducing readmissions. This year there were more serious errors in transition from other
facilities, with 26.4% of these errors in the serious category.
Bed Type
Many nursing homes in NC also maintain adult care (assisted living) units or floors within their facility,
in addition to skilled nursing. Though the need to record errors for this group is noted in the legislation
(“Nursing home means a nursing home licensed under this Chapter and includes an adult care home
operated as part of a nursing home”, Senate Bill 1016), prior to 2010 we did not track which errors were
from adult care beds compared to skilled nursing beds. In 2010 nursing homes started recording whether
the error occurred within a skilled nursing bed or adult care bed. In 2012, 86.6% of errors were reported
as skilled nursing, 4.9% in adult care, and 8.5% as unknown/not applicable.
9
MEQI REPORTS
Patient Characteristics
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Age Group
64 yrs or younger 2,246 15.5 10,067 16.3 92.1 7.9
65-74 years 2,808 19.3 11,320 18.3 90.2 9.8
75-84 years 4,287 29.5 18,216 29.5 90.7 9.3
85 years or older 4,673 32.2 20,217 32.8 90.1 9.9
na 512 3.5 1,910 3.1 100.0 0
Gender
Female 9,913 68.2 41,305 66.9 90.7 9.3
Male 4,101 28.2 18,515 30.0 90.5 9.5
na 512 3.5 1,910 3.1 100.0 0
Cognitive Ability
Patient able to direct own
care
4,049 27.9 16,264 26.3 89.6 10.4
Patient unable to direct
own care
9,504 65.4 41,548 67.3 91.0 9.0
Unknown 461 3.2 2,008 3.3 91.3 8.7
na 512 3.5 1,910 3.1 100.0 0
Number of Medications Daily
01 - 05 meds 214 1.5 751 1.2 93.5 6.5
06 - 10 meds 1,199 8.3 4,673 7.6 87.3 12.7
11 - 15 meds 1,395 9.6 6,326 10.2 86.6 13.4
16 - 20 meds 587 4.0 3,517 5.7 89.4 10.6
20 or more meds 240 1.7 1,114 1.8 85.4 14.6
Not reported 10,891 75.0 45,349 73.5 92.1 7.9
Patient Transition
From Home 68 0.5 326 0.5 86.8 13.2
From Hospital 1,658 11.4 10,129 16.4 88.8 11.2
From Other facility 53 0.4 503 0.8 73.6 26.4
Not Transitioning 12,747 87.8 50,772 82.2 91.3 8.7
Bed Type
Adult Care Bed 713 4.9 2,956 4.8 91.6 8.4
Skilled Nursing 12,576 86.6 52,092 84.4 90.6 9.4
na 1,237 8.5 6,682 10.8 94.0 6.0
10
Types of Error
The two most common types of errors in 2012 remain dose omission and wrong documentation. Forty-four
percent (6,438) are dose omission errors, and 19.1 percent are wrong documentation errors.
Other commonly reported types of errors are overdose/multiple dose at 7.0%, wrong strength at 6.5%,
wrong product at 4.0%, wrong patient at 3.5%, and wrong time at 3.1%. Wrong patient with 23.6%
serious errors remains a continued area of concern, with very litle change in the number of errors, or
seriousness of errors, over time.
MEQI REPORTS
Type of Error
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Type of Error
Dose Omission 6,438 44.3 22,349 36.2 93.4 6.6
Wrong documentation 2,769 19.1 15,154 24.5 94.4 5.6
Overdose 1,014 7.0 5,688 9.2 83.8 16.2
Wrong strength 941 6.5 4,256 6.9 88.9 11.1
Wrong product 577 4.0 1,375 2.2 89.8 10.2
Wrong patient 512 3.5 845 1.4 76.4 23.6
Wrong time 447 3.1 1,530 2.5 91.9 8.1
Underdose 398 2.7 3,043 4.9 85.7 14.3
Expired order 338 2.3 2,989 4.8 93.5 6.5
Labwork error 277 1.9 423 0.7 85.2 14.8
Monitoring error 269 1.9 676 1.1 77.7 22.3
Wrong duration 266 1.8 2,409 3.9 92.5 7.5
Wrong technique 78 0.5 272 0.4 85.9 14.1
Wrong form 70 0.5 246 0.4 91.4 8.6
Product Allergy 48 0.3 111 0.2 77.1 22.9
Wrong rate of
administration
38 0.3 170 0.3 78.9 21.1
Expired product 23 0.2 162 0.3 73.9 26.1
Wrong route 23 0.2 32 0.1 73.9 26.1
11
MEQI REPORTS
Medications Involved in Error
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Medications
Warfarin 786 5.4 1,890 3.1 69.1 30.9
Insulin 671 4.6 2,375 3.8 76.0 24.0
Oxycodone 466 3.2 1,212 2.0 90.8 9.2
Hydrocodone 446 3.1 1,198 1.9 93.3 6.7
Lorazepam 434 3.0 970 1.6 91.9 8.1
Fentanyl 308 2.1 370 0.6 84.1 15.9
Furosemide 302 2.1 1,678 2.7 87.7 12.3
Alprazolam 240 1.7 648 1.0 94.6 5.4
Metoprolol 236 1.6 1,134 1.8 92.4 7.6
Omeprazole 232 1.6 941 1.5 98.7 1.3
Clonazepam 216 1.5 546 0.9 92.6 7.4
Aspirin 207 1.4 1,855 3.0 97.1 2.9
Potassium chloride 192 1.3 955 1.5 93.2 6.8
Levothyroxine 189 1.3 811 1.3 94.2 5.8
Polyethylene glycol 154 1.1 838 1.4 97.4 2.6
Zolpidem 153 1.1 653 1.1 89.5 10.5
Docusate 146 1.0 821 1.3 98.6 1.4
Morphine 144 1.0 490 0.8 86.8 13.2
Gabapentin 142 1.0 760 1.2 97.9 2.1
Mirtazapine 139 1.0 786 1.3 98.6 1.4
Quetiapine 128 0.9 960 1.6 93.0 7.0
Acetaminophen 127 0.9 506 0.8 95.3 4.7
Lisinopril 125 0.9 611 1.0 91.2 8.8
Simvastatin 120 0.8 567 0.9 98.3 1.7
Mmultivitamin 119 0.8 420 0.7 97.5 2.5
Calcium-vitamin D 117 0.8 681 1.1 99.1 0.9
Enoxaparin 108 0.7 329 0.5 84.3 15.7
Tramadol 104 0.7 467 0.8 92.3 7.7
Clonidine 103 0.7 225 0.4 79.6 20.4
Other drug 7,672 52.8 36,033 58.3 93.6 6.7
12
Medications Involved in Error
There were 654 diferent medications reported in errors for FY2012. 566 of these were reported in more
than one error, and 309 in more than 5 errors. Warfarin (786) is the most common medication involved
in errors, followed by insulin (671), oxycodone combinations (466), hydrocodone combinations (446),
lorazepam (434) and fentanyl (308). Many of these common medications in NC nursing home errors
also are consistently included on lists of dangerous medications and on lists of medications that are
cautioned for use in the elderly. Aside from warfarin and insulin, the other most common medications
are controlled substances. The 29 most common types of medications involved in error incidents in NC
are listed in the table. They each have over 100 errors and together account for nearly one half of all
error incidents. Within this list there
are three medications that are more
than twice as likely to have serious
outcomes: warfarin (30.9% serious),
insulin (24% serious), and clonidine
(20.4% serious).
Therapeutic Class
Medications involved in error have
been grouped by the therapeutic
class codes found in the Multum
Cerner medication database. The
medications are grouped into
seventeen diferent classes. Over one
quarter (27.6%) of the errors (4,012)
are classified as central nervous
system agents. Central nervous
system agents include narcotics,
analgesics, anticonvulsants and
sedatives. Other therapeutic classes
with over 1000 errors each are
cardiovascular agents (10.7%),
metabolic agents (includes the
various insulin products) (8.6%),
nutritional products (8.5%),
coagulation modifiers (8.3%),
and gastrointestinal agents
(7.7%). Coagulation modifiers
(anticoagulants), which include
warfarin, enoxaparin, and heparin,
is the class with the most serious
outcomes – with 22.2% of errors
(268 serious errors) in this class
leading to an error with an outcome
category 4-9.
MEQI REPORTS
Medications Involved in Error by
Therapeutic Class Name
FY 2012
Error
Incidents
% Minor % Serious %
All Errors 14,526 100.0 91.0 9.0
Therapeutic Class
central nervous
system agents
4,012 27.6 92.0 8.0
cardiovascular agents 1,551 10.7 90.0 10.0
metabolic agents 1,256 8.6 85.4 14.6
nutritional products 1,240 8.5 94.8 5.2
coagulation modifiers 1,207 8.3 77.4 22.6
gastrointestinal
agents
1,116 7.7 97.4 2.6
anti-infectives 980 6.7 88.8 11.2
psychotherapeutic
agents
916 6.3 94.0 6.0
topical agents 615 4.2 95.9 4.1
miscellaneous agents 448 3.1 93.5 6.5
respiratory agents 433 3.0 96.5 3.5
hormones/hormone
modifiers
364 2.5 92.9 7.1
biologicals 95 0.7 88.4 11.6
genitourinary tract
agents
90 0.6 95.6 4.4
antineoplastics 87 0.6 92.0 8.0
alternative medicines 77 0.5 98.7 1.3
immunologic agents 37 0.3 83.8 16.2
radiologic agents 2 0.0 100.0 0
13
Efects of Errors on Patients
In this section, nursing homes are asked to report the efect of the error on the patient and more than
one efect can be noted. As in prior years most errors were reported as having no injury or efect. For FY
2012, 13,572 or 93.0% of reported errors had no injury or physical efect. Only 1024 of the errors reported
noted a physical efect of the error. The most common reported efect, with 341 errors (33% of error
efects), is inadequate efect of medication. This is primarily related to dose omission errors, where the
resident did not receive their medication. Other efects that were commonly reported include: increase/
decrease in PT/INR (175) which is a test used to look at the efect of anticoagulants (such as warfarin)
and blood cloting, increase or
decrease in blood sugar (97)
often found in conjunction
with insulin use, pain (70),
somnolence/lethargy (55), and
change in blood pressure(55).
Cause of Errors
The most commonly reported
cause of error this year was
‘staf did not follow policies
and procedures’, with 60.3% of
errors reporting this as a cause.
Other common causes include
transcription error (21.7%),
distractions on floor (4.9%),
poor communication (2.9%), and
medication unavailable (1.8%).
These are the same five most
common causes as in prior years.
Each year there are diferent
causes involved in serious error,
with very litle overlap from
year to year. In 2012 there are
four causes of errors that are
more than twice as likely to have
serious outcomes; however,
some of these are indicated in
only a small number of errors;
poor communication (22.1%
serious), too much workload/
overtime (20.8 % serious), use of
abbreviations (30% serious), and
pharmacy delivered to wrong
facility (33.3% serious).
MEQI REPORTS
Efects of Error on Patient
FY 2012
Error
Incidents
% Repeat
Errors
%
All Errors 14,596 100.0 62,150 100.0
Efects
no injury or efect 13,572 93.0 57,163 92.0
Inadequate efect 341 2.3 1,901 3.1
PT/INR increase/decrease 175 1.2 471 0.8
Change in blood sugar 97 0.7 481 0.8
Pain 70 0.5 166 0.3
Somnolence/lethargy 55 0.4 181 0.3
Change in blood pressure 55 0.4 218 0.4
Excessive side efects 34 0.2 143 0.2
Agitation/anxiety 30 0.2 179 0.3
Sleep change 30 0.2 95 0.2
Mood change 24 0.2 293 0.5
Constipation/Diarrhea 18 0.1 112 0.2
Nausea/Vomiting 15 0.1 71 0.1
Weight change 14 0.1 142 0.2
Edema 14 0.1 129 0.2
Cognitive change 11 0.1 80 0.1
Respiratory distress 9 0.1 16 0.0
Allergic reaction 7 0.0 12 0.0
Fall 6 0.0 51 0.1
Appetite change 4 0.0 81 0.1
Wound/fracture/bruise 4 0.0 8 0.0
Seizure 4 0.0 72 0.1
Headache 3 0.0 4 0.0
Visual disturbance 2 0.0 4 0.0
GI bleed 2 0.0 77 0.1
14
Phase Where Errors Occur
Nursing homes also report in which of the five process phases the medication error initially occurred.
Most errors reported are those that occur within the nursing home itself, with 57.1% in medication
administration, 37% in the documentation phase, and 3.4% during the monitoring phase. The largest
percentage of repeat errors continues to be those related to documentation; these account for over 63%
of repeat errors. This year we saw an increase of serious errors in the monitoring phase–this is possibly
related to the high number of errors in warfarin and insulin, both of which cause more serious errors
and require a high level of monitoring. In 2012 only 0.5 % of the errors were reported in the prescribing
phase (74 errors) and 1.9% in dispensing (283 errors). These two types of errors are usually reported in
our system only if discovered or identified by nursing home staf. There was again a noticeable decrease
in dispensing errors reported this year, from 4.8% of total in 2010 to 3.0% in 2011 and to 1.9% in 2012.
MEQI REPORTS
Cause of Error
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 16,931 100.0 75,036 100.0 89.7 10.3
Primary Personnel
Staf did not follow policies 10,210 60.3 33,101 44.1 91.7 8.3
Transcription error 3,666 21.7 30,199 40.2 88.5 11.5
Distractions on floor 836 4.9 2,719 3.6 84.8 15.2
Poor Communication 485 2.9 2,113 2.8 77.9 22.1
Med unavailable 306 1.8 954 1.3 89.2 10.8
Pharmacy dispensing 243 1.4 1,548 2.1 89.3 10.7
Name confusion 205 1.2 644 0.9 86.8 13.2
Current policies faulty 143 0.8 490 0.7 82.5 17.5
Inadequate info 127 0.8 710 0.9 88.2 11.8
Improper training 121 0.7 276 0.4 84.3 15.7
Package design 108 0.6 207 0.3 82.4 17.6
Pharm delivered wrong med 90 0.5 495 0.7 90.0 10.0
Shift change 82 0.5 166 0.2 85.4 14.6
Illegible handwriting 75 0.4 751 1.0 86.7 13.3
Product label 71 0.4 314 0.4 90.1 9.9
Too much workload/overtime 48 0.3 137 0.2 79.2 20.8
Exhaustion 40 0.2 73 0.1 82.5 17.5
Emergency on floor 36 0.2 46 0.1 80.6 19.4
Poor working conditions 15 0.1 15 0.0 86.7 13.3
Use of Abbreviations 10 0.1 42 0.1 70.0 30.0
Pharmacy closed 8 0.0 16 0.0 87.5 12.5
Pharm delivered to wrong facility 6 0.0 20 0.0 66.7 33.3
15
Personnel Involved in Error
Nurses, both RN and LPN, are primarily responsible for
the delivery of medications in nursing homes. In 2012
LPNs, who are the most common caregivers and were
involved in most medication error incident reports
(69.4%), while RNs were involved in 22.6%. Medication
aides were involved in 4.1% of errors. Pharmacists or
pharmacy staf account for another 2.9% of errors
(a reduction from 5.1% in 2010, then 3.5% in 2011).
In 161 errors (1.1%) the primary personnel involved
in the error was listed as a temporary, contract, or
agency staf. Students/trainees or patient/caregiver
errors are often more serious, but account for very
few errors.
MEQI REPORTS
Phase of Error Occurence
FY 2011
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Phase
Administering 8,296 57.1 19,372 31.4 90.9 9.1
Documenting 5,377 37.0 39,000 63.2 91.9 8.1
Monitoring 496 3.4 855 1.4 81.5 18.5
Dispensing 283 1.9 1,825 3.0 89.4 10.6
Prescribing 74 0.5 678 1.1 93.2 6.8
MEQI Reports
Phase of Error Occurrence
FY 2012
1.95% 0.51%
5377
37.02%
8296
57.11%
3.41%
Errors
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Medication Phase
Administering Documenting Monitoring Dispensing Prescribing
MEQI Reports
Number of Errors for Each Personnel Category
FY 2012
PCT.
69.45
22.59
4.09
0.47
2.86
0.03
0.18
0.05
0.18
0.10
Personnel
Physician Assistant
Patient or Caregiver
Nurse Aide/CNA
Student or Trainee
Nurse Practitioner
Physician
Pharmacist/Pharm Tech
Medication Aide
RN
LPN
Number of Errors
0 2000 4000 6000 8000 10000 12000
MEQI Reports
Errors by Work Shift
FY 2012
7540
51.91%
5759
39.65%
1227
8.45%
Percent
0
10
20
30
40
50
60
Shift
7am to 3pm 3pm to 11pm 11pm to 7am
16
Work Shift
Each error is also assigned to the work shift in which the error occurred, or if unknown, the shift
where the error was identified. About half (51.9%) of all errors continue to be noted as day shift
incidents (7am to 3pm). Another 39.6% were noted as the afternoon/evening shift incidents
(3pm to 11pm). A smaller number of errors (8.4%) were noted as nightshift incidents (11pm to
7am). Since most medications are administered during the day and evening shifts, more errors
would be anticipated during these shifts compared to the night shift. For FY 2012 there was litle
variation in serious outcomes among shifts.
MEQI REPORTS
Work Shift of Error Occurrence
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Work Shift
7am to 3pm 7,540 51.9 38,372 62.2 91.3 8.7
3pm to 11pm 5,759 39.6 20,318 32.9 90.7 9.3
11pm to 7am 1,227 8.4 3,040 4.9 89.8 10.2
MEQI REPORTS
Personnel
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Primary Personnel
LPN 10,088 69.4 41,976 68.0 91.5 8.5
RN 3,281 22.6 13,577 22.0 89.8 10.2
Medication Aide 594 4.1 2,076 3.4 90.2 9.8
Pharmacist/Pharm Tech 416 2.9 2,688 4.4 89.9 10.1
Physician 68 0.5 787 1.3 94.1 5.9
Nurse Practitioner 26 0.2 155 0.3 92.3 7.7
Student or Trainee 26 0.2 51 0.1 50.0 50.0
Nurse Aide/CNA 15 0.1 292 0.5 93.3 6.7
Patient or Caregiver 7 0.0 19 0.0 71.4 28.6
Physician Assistant 5 0.0 109 0.2 100.0 0.0
Primary Personnel involved was temporary or contract staf at time of error
No 14,243 98.1 59,648 96.6 90.9 9.1
Yes 161 1.1 574 0.9 88.2 11.8
Unknown 122 0.8 1,508 2.4 95.1 4.9
17
Conclusion
The MEQI project has now collected medication errors from nursing homes for nine years. This is
the final year of data collection for the project. What began with a simple online year end form
has expanded to include an individual error entry system that could be used year-round. Over
time we added site specific summary data reports, graphic reports, and a toolkit, all to enhance
the user experience. Many of the 400 nursing homes participated with us in making these
changes, responding to surveys and participating in pilot tests and key informant interviews to
give us feedback and improve the system.
Most errors reported to the MEQI system over time have not harmed the patient, and have
resulted in no injury or efect on the patient. It is a small number of errors, around 9% that are
an area for concern, and a smaller percentage yet, about 1% that lead to what most national
definitions would consider to be patient harm. The goal of most nursing homes should be to
address system issues that lead to the repetition of the most harmful medication errors. It is
also clear that facilities have varying ideas about what an error is, and interpret reportable error
guidelines diferently from one another. Some homes consistently report under 20 errors per year
(in some cases 0), and some report over 1000 errors per year. This understanding of reporting
does not, as far as we can tell, relate to the quality of any particular nursing home, but rather
to the leadership staf and how they interpret the guidance provided. Error report numbers on
a facility level are not useful for determining facility quality, but on a larger scale can provide
valuable information on specific medications, and types of error for targeting interventions.
Medication Error Quality Initiative
Improving Medication Safety in
North Carolina Nursing Homes
MEQRX I

Medication Error Quality Initiative (MEQI)
October 1, 2011 to September 30, 2012
ANNUAL REPORT
2012
Medication Error Quality Initiative
Improving Medication Safety in
North Carolina Nursing Homes
MEQRX I
2
Medication Error Quality Initiative (MEQI)
Cecil G. Sheps Center for Health Services Research
The University of North Carolina at Chapel Hill
CB #7590, 725 Martin Luther King Jr. Blvd.
Chapel Hill, NC 27599-7590
For more information contact:
Charlotte Williams, Project Manager
Phone: 919-966-7927
Email: meqi@shepscenter.unc.edu
PROJECT WEBSITE:
htp://www.shepscenter.unc.edu/meqi
This report is produced by the Cecil G. Sheps Center for Health Services Research (Sheps Center)
at the University of North Carolina at Chapel Hill for the North Carolina Department of Health
and Human Services, Division of Health Service Regulation.
Funded by:
The North Carolina Department of Health and Human Services, Contract #00022236
Authors:
Charlote E. Williams, MPH1, Sandra B. Greene, DrPH1; Richard A. Hansen, PhD2; Stephanie
Pierson, MSHI1; and Rishi Desai, MS 4
1 Cecil G. Sheps Center for Health Services Research at the University of North Carolina at
Chapel Hill, Chapel Hill, NC
2 Harrison School of Pharmacy, Auburn University, Auburn, Alabama
4 UNC Eschelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel
Hill, NC.
Suggested Citation: Williams CE, Greene SB, Hansen RA , Pierson S, and Desai, R. NC Nursing
Home Medication Error Quality Initiative (MEQI), Annual Report FY2012, October 1, 2011 to
September 30, 2012. Chapel Hill, NC. The Cecil G. Sheps Center for Health Services Research at
the University of North Carolina at Chapel Hill.
Medication Error Quality Initiative
Improving Medication Safety in
North Carolina Nursing Homes
MEQRX I
3
Table of Contents
(Page 4) MEQI Project
(Page 4) Highlights
(Page 4) Anti-Coagulation Research
(Page 5) Therapeutic Class Research
(Page 5) Analgesics Research
(Page 5) FY 2012 Data Summary
(Page 6) Table: 2009-2012 Data Summary
(Page 6) Graph : Errors per Nursing Home, FY 2012
(Page 7) Patient Outcomes
(Page 7) Table: Patient Outcomes: Definition of Minor/Serious
(Page 7) Table: Patient Outcomes FY 2012
(Page 8) Patient Characteristics
(Page 9) Table: Patient Characteristics FY 2012
(Page 10) Types of Error
(Page 10) Table: Type of Error FY2012
(Page 11) Table Medications Involved in Error FY2012
(Page 12) Medications Involved in Error
(Page 12) Therapeutic Class
(Page 12) Table: Therapeutic Class Involved in Error FY2012
(Page 13) Efects of Error on Patients
(Page 13) Table: Efects of Error FY2012
(Page 13) Cause of Error
(Page 14) Table: Cause of Error FY2012
(Page 14) Phase Where Errors Occur
(Page 15) Table: Phase of Error Occurrence FY2012
(Page 15) Graph: Phase of Error Occurrence Chart FY2012
(Page 15) Graph: Primary Personnel FY2012
(Page 15) Personnel Involved in Error
(Page 15) Graph: Errors by Works Shift, FY 2012
(Page 16) Table: Personnel, FY2012
(Page 17) Work shift
(Page 17 Table: Work Shift of Error Occurrence, FY2012
(Page 18) Conclusion
Notes on Tables and Graphs
• Patient Characteristics Table - errors in category one (circumstances) do not include patient information as no patient was
involved.
• See the Patient Outcome section in the narrative for a definition of Minor and Serious Outcomes. Some national studies choose
not to use patient outcome 4 as a serious error. These errors have been intentionally included in MEQI Serious Errors because any
error with an efect that requires monitoring and/or intervention to preclude harm should be regarded as a serious error.
• Serious Outcomes are highlighted in red within the chart in some tables if they are double the average number of serious errors.
4
MEQI FY2012
The MEQI Project
The Medication Error Quality Initiative, or MEQI, is a North Carolina nursing home medication error
reporting system, as required by NC Senate Bill 1016 (2003). All state licensed nursing homes have
reported medication errors since January 2004, initially using an online annual summary system.
Beginning in 2006, nursing homes transitioned to an improved online system where errors are entered
individually as they occur throughout the year. Since 2009 all nursing homes have used the new system.
398 nursing homes currently are participating in reporting. Due to a lack of funding, this will be the final
year of the MEQI Project. The section of the law which requires reporting is intended to be repealed.
Though reporting is ending, nine years of focus and atention to medication errors has brought a new
awareness of patient safety to NC nursing homes.
Highlights
• A reduction in reporting of pharmacy dispensing errors has continued this year.
• Warfarin and insulin continue to be involved in large numbers of errors, many of those with
serious outcomes.
• Warfarin errors are likely to be caused by transcription errors, communication problems,
inadequate information, and shift change. These areas should be addressed if warfarin
errors are common in your facility.
• Drugs in these classes—anxiolytics/sedatives/hypnotics, anti-diabetic agents, anticoagulants,
anticonvulsants, and ophthalmic preparations—are more likely to be reported in errors after
considering how often the various drug classes are used by nursing home residents.
• Medication errors still occur commonly during transitions from hospital, home or other
facility. Atention to this area has reduced serious errors, but errors still commonly occur.
Anti - Coagulation Research
MEQI staf has completed an analysis of the anticoagulant medication errors occurring over a two year
period. Anticoagulant medications include warfarin, enoxaparin, and heparin. Warfarin is the most
common drug involved in error in 2012. Research shows a relationship between this type of medication
error and patient harm, and identifies areas nursing homes could target for preventing anticoagulant
errors. Of 32,176 medication error incidents reported over a 2-year period, 1,623 (5%) were anticoagulant
medication errors and 2% of these errors (n=29) resulted in patient harm. Anticoagulant medication
errors had higher odds of patient harm when compared with other errors (OR=1.79, 95% CI: 1.20-
2.66), and anticoagulant errors were significantly more likely than other drug errors to be caused by
transcription error, communication problems, inadequate information, and shift change (p<0.05 for all).
Desai, R., Williams, C.E., Greene S.B., Pierson S. and Hansen R.A. “Anticoagulant medication errors in
nursing homes: characters, causes, outcomes and association with patient harm”, Journal of Healthcare
Risk Management, (accepted for publication November 2012)
5
Therapeutic Class Research
In another analysis, MEQI staf identified 10 drug classes most frequently involved in medication errors.
Patient characteristics and impact of these medication errors on patients were further examined.
The MEQI data were combined with data from the 2004 National Nursing Home Survey (NNHS) to
compare medication usage to medication error occurrence. There were 32,176 individual medication
errors reported to MEQI in years 2010-11. The 10 drug classes most commonly involved in medication
errors were analgesics (12.27%), anxiolytics/sedative/hypnotics (8.39%), anti-diabetic agents (5.86%),
anticoagulants (5.04%), anticonvulsants (4.05%), antidepressants (4.05%), laxatives (3.13%), ophthalmic
preparations (2.77%), antipsychotics (2.47%) and diuretics (2.34%). The analysis suggests that certain
drug classes are more likely to be involved in medication errors in NH patients regardless of the extent of
their use. The drug classes frequently and disproportionately involved in errors in nursing homes include
anxiolytics/sedatives/hypnotics, anti-diabetic agents, anticoagulants, anticonvulsants, and ophthalmic
preparations. Beter understanding of the causes and prevention strategies to reduce these errors may
improve NH patient safety.
Desai, R., Williams, C.E., Greene S.B., Pierson S., Caprio A. and Hansen R.A. “Exploratory evaluation of
medication classes most commonly involved in nursing home errors”, Journal of the American Medical
Directors Association, (accepted for publication November 2012)
Analgesics Research
MEQI staf also is in the process of conducting research focused on analgesic medication errors and their
association with patient harm. A total of 32,176 individual medication error incidents were reported over
a 2-year period in North Carolina nursing homes, 12.3% (n=3,949) of which were analgesic medication
errors. Of these analgesic medication errors, opioid and non-opioid analgesics were involved in 3,105
and 844 errors respectively. The initial analysis indicates that opioid errors are more likely to be wrong
drug errors, wrong dose errors, and administration errors compared to non-opioid errors (p<0.0001 for
all comparisons), and had an increased likelihood of patient harm compared with non-opioid analgesics.
FY 2012 Data Summary
This report provides data submited during fiscal year 2012 (October 1, 2011 to September 30, 2012).
For FY 2012, all North Carolina nursing homes submited medication error incidents and also completed
a year-end form to verify that submission was complete. Although it is mandatory to report all errors
and potential errors, the completeness of reporting varies. The number of errors reported by individual
facilities in FY 2011 ranges from 0 to 1559, a range which is not correlated with the size of the facility.
Sites are also asked to report if any medication-related liability claims had been filed against their facility
during the year. One nursing home reported 2 medication-related liability claims in FY 2012.
A total of 14,526 error incidents were reported in FY 2012 by 398 nursing homes. The mean number of
error incidents per nursing home was 36, with an average of 30 errors per 100 beds. The median number
of errors was 19 per facility. This is a decrease of 2,465 reported errors from the FY2011 report (a 14.5
% decrease) for the same number of facilities. This decrease appears to be almost entirely atributed to
two high volume reporting sites. The cause of the drop in reporting volume is unknown, though it could
be related to turnover in a leadership position (director of nursing or administrator), or a change in how
these facilities identify or report errors. The reduction is noticed primarily in outcome Category 2 (error
occurred, but did not reach the patient) and in the ‘wrong documentation’ type of error.
6
Of the 14,526 errors, 4,988 (34.3%) were repeated at least once and, for this year’s data, there was
an average of 12.3 repeats before the error was discovered. There were a total of 61,730 total repeat
occurrences of errors including the original error, which is an average of 155 repeat errors per nursing
home. An example of a repeated error would be a situation where a physician orders that a drug be
discontinued, but this discontinuation does not get recorded in the Medication Administration Record
(MAR), resulting in the drug being administered to the resident for five additional days. This would be
reported by a nursing home as one error incident, but the form would indicate that there were five
repeat occurrences of the error.
MEQI Reports
Error Incidents per Nursing Home
FY 2012
Number of Nursing Homes
0
10
20
30
40
50
60
70
80
90
100
110
Error Incidents Per Nursing Home
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 100+
MEQI Reports
Summary Data
FY 2012
Fiscal Year
2012 2011 2010 2009
Number of nursing homes 398 398 397 395
Total number of error incidents 14,526 16,974 15,202 14,395
Number of error incidents with 1+
repeats
4,988 5,270 5,456 5,064
Total errors including repeats 61,730 67,941 66,256 59,558
Mean error incidents 36 43 38 36
Median error incidents 19 21 20 22
Incidents per 100 beds 30 35 32 31
7
The data summary table shows results for the last four years, FY 2009 – FY 2012. A graph is also provided
that shows the numbers of error incidents per nursing homes. This graph shows that about half of the
nursing homes reported between 0 and 19 errors in FY 2011. Another 25% of homes reported between
20 and 39 errors, and the last 25% reported more than 40 errors. Accounting for nursing home bed
size has very litle impact on these results. Though
some variation of errors might be accounted for
by the quality of the nursing home, this large
variation in errors suggests that all nursing homes
may not use the same standards for what kinds of
errors are reported.
Patient Outcomes
All errors are categorized by those who submit the
error into one of nine patient outcomes. The nine
outcomes have then been further categorized by
MEQI into a minor or serious outcome category.
The minor errors are those where no patient was
involved, the error does not reach the patient, or
where the error reached the patient but there
was no harm or efects (i.e. dose omission with no
physical efects). Those errors placed in the serious
category are those where ongoing monitoring or
intervention were needed, or an error where the
patient was harmed temporarily or permanently.
Patient Outcomes: Definition of Minor/Serious
MINOR
ERROR
OUTCOMES
1 Capacity to cause error; no patient involved
2 Error occurred; but did not reach the patient
3 Error occurred and reached the patient, but did
not cause harm (dose omission with no efecte
should be included here)
SERIOUS
ERROR
OUTCOMES
4 Error occurred and reached the patient and
required monitoring and/or intervention to
preclude harm
5 Error occurred and reached the patient and
resulted in temporary patient harm
6 Error occurred and reached the patient and
resulted in temporary harm, requiring a trip to
Emergency Department
7 Error Occurred and reached the patient and
contribued to permanent patient harm
8 Error occurred and reached the pateint and
resulted in intervention necessary to sustain life
9 Error occurred and reached the patient and
contributed to the patient’s death
MEQI REPORTS
Patient Outcomes
FY 2012
Error
Incidents
% Repeat
Errors
%
All Errors 14,526 100.0 61,730 100.0
Patient Outcome
1=Capacity to cause error 512 3.5 1,910 3.1
2=Did not reach patient 674 4.6 1,761 2.9
3=Reached the patient but did not cause any
harm
12,026 82.8 52,216 84.6
4=Required monitoring/intervention to
preclude harm
1,193 8.2 5,295 8.6
5=Temporary harm to patient 93 0.6 346 0.6
6=Temporary harm with trip to ER 28 0.2 202 0.3
7=Permanent patient harm 0 0.0 0 0.0
8=Intervention necessary to sustain life 0 0.0 0 0.0
9=Patient death 0 0.0 0 0.0
8
For FY 2012, 91.0% of errors were in the minor outcome categories and 9.0% were in the serious outcome
categories. This is a slight increase in the percentage of serious errors from FY2011, but this is most likely
related to the reduction of non-serious errors reported by two high volume nursing homes. Of the 91.0%
minor errors, 8.1% were either a situation where there was a capacity for error, or the error was stopped
before it reached the patient and 82.8% were errors that reached the patient, but caused no harm. Of
the 9.0% serious outcome errors, nearly all were errors that required monitoring and/or intervention
to preclude harm (8.2% of total). Only 121 errors (0.8%) lead to temporary harm to the patient (with or
without ED visit). In 2012 there were no incidents reported in the three most serious patient outcome
categories (permanent patient harm, intervention necessary to sustain life or death).
Patient Characteristics
Errors by Age Group and Gender
By age group, 15.5% of NC nursing home patients afected by medication errors this year are under 65
(2,246 errors), 19.3% between ages 65-74 (2,808 errors), 29.5% between the ages of 75-84 (4,287), and
32.2% 85 years or older (4,673). The age of patient does not appear to be related to the seriousness of
the error. However, based on the national nursing home survey from 2004, it would be expected that
about 12% of residents are younger than 65 years of age, 12% between 65-74, 32% between 75-84, and
45% over 85. It would appear that errors are proportionally more likely to afect the younger nursing
home population (under 74) more often than the over 85 population; however this does not take into
account the number of medications and doses in each age group. Further research is needed in this area.
Regarding gender, 68.2% of the errors reported were for patients who were female and 28.2% were male,
which is similar to the gender distribution of the national nursing home population of 71.2% female and
28.8% male (National Nursing Home Study 2004).
Resident’s Ability to Direct Their Own Care
Nursing home staf members who record errors are asked to identify whether the patient is able or
unable to direct their own care. 27.9 % of errors involve residents identified as able to direct their own
care, and 65.4% involve residents who are unable to direct their own care.
Errors during Transitions of Care
Whether the error occurred while the patient was transitioning into the nursing home from their home,
hospital or another facility was also recorded, and such a transition is noted in 12.2% of error incidents.
A total of 1,779 errors occurred in transition, 68 from home (0.5%), and 1,658 from hospital (11.4%) and
53 from another facility (0.4%). Over time we have seen a reduction in the number of serious errors in
transition from both home and hospital–most likely due to the national focus on this topic and the new
emphasis on reducing readmissions. This year there were more serious errors in transition from other
facilities, with 26.4% of these errors in the serious category.
Bed Type
Many nursing homes in NC also maintain adult care (assisted living) units or floors within their facility,
in addition to skilled nursing. Though the need to record errors for this group is noted in the legislation
(“Nursing home means a nursing home licensed under this Chapter and includes an adult care home
operated as part of a nursing home”, Senate Bill 1016), prior to 2010 we did not track which errors were
from adult care beds compared to skilled nursing beds. In 2010 nursing homes started recording whether
the error occurred within a skilled nursing bed or adult care bed. In 2012, 86.6% of errors were reported
as skilled nursing, 4.9% in adult care, and 8.5% as unknown/not applicable.
9
MEQI REPORTS
Patient Characteristics
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Age Group
64 yrs or younger 2,246 15.5 10,067 16.3 92.1 7.9
65-74 years 2,808 19.3 11,320 18.3 90.2 9.8
75-84 years 4,287 29.5 18,216 29.5 90.7 9.3
85 years or older 4,673 32.2 20,217 32.8 90.1 9.9
na 512 3.5 1,910 3.1 100.0 0
Gender
Female 9,913 68.2 41,305 66.9 90.7 9.3
Male 4,101 28.2 18,515 30.0 90.5 9.5
na 512 3.5 1,910 3.1 100.0 0
Cognitive Ability
Patient able to direct own
care
4,049 27.9 16,264 26.3 89.6 10.4
Patient unable to direct
own care
9,504 65.4 41,548 67.3 91.0 9.0
Unknown 461 3.2 2,008 3.3 91.3 8.7
na 512 3.5 1,910 3.1 100.0 0
Number of Medications Daily
01 - 05 meds 214 1.5 751 1.2 93.5 6.5
06 - 10 meds 1,199 8.3 4,673 7.6 87.3 12.7
11 - 15 meds 1,395 9.6 6,326 10.2 86.6 13.4
16 - 20 meds 587 4.0 3,517 5.7 89.4 10.6
20 or more meds 240 1.7 1,114 1.8 85.4 14.6
Not reported 10,891 75.0 45,349 73.5 92.1 7.9
Patient Transition
From Home 68 0.5 326 0.5 86.8 13.2
From Hospital 1,658 11.4 10,129 16.4 88.8 11.2
From Other facility 53 0.4 503 0.8 73.6 26.4
Not Transitioning 12,747 87.8 50,772 82.2 91.3 8.7
Bed Type
Adult Care Bed 713 4.9 2,956 4.8 91.6 8.4
Skilled Nursing 12,576 86.6 52,092 84.4 90.6 9.4
na 1,237 8.5 6,682 10.8 94.0 6.0
10
Types of Error
The two most common types of errors in 2012 remain dose omission and wrong documentation. Forty-four
percent (6,438) are dose omission errors, and 19.1 percent are wrong documentation errors.
Other commonly reported types of errors are overdose/multiple dose at 7.0%, wrong strength at 6.5%,
wrong product at 4.0%, wrong patient at 3.5%, and wrong time at 3.1%. Wrong patient with 23.6%
serious errors remains a continued area of concern, with very litle change in the number of errors, or
seriousness of errors, over time.
MEQI REPORTS
Type of Error
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Type of Error
Dose Omission 6,438 44.3 22,349 36.2 93.4 6.6
Wrong documentation 2,769 19.1 15,154 24.5 94.4 5.6
Overdose 1,014 7.0 5,688 9.2 83.8 16.2
Wrong strength 941 6.5 4,256 6.9 88.9 11.1
Wrong product 577 4.0 1,375 2.2 89.8 10.2
Wrong patient 512 3.5 845 1.4 76.4 23.6
Wrong time 447 3.1 1,530 2.5 91.9 8.1
Underdose 398 2.7 3,043 4.9 85.7 14.3
Expired order 338 2.3 2,989 4.8 93.5 6.5
Labwork error 277 1.9 423 0.7 85.2 14.8
Monitoring error 269 1.9 676 1.1 77.7 22.3
Wrong duration 266 1.8 2,409 3.9 92.5 7.5
Wrong technique 78 0.5 272 0.4 85.9 14.1
Wrong form 70 0.5 246 0.4 91.4 8.6
Product Allergy 48 0.3 111 0.2 77.1 22.9
Wrong rate of
administration
38 0.3 170 0.3 78.9 21.1
Expired product 23 0.2 162 0.3 73.9 26.1
Wrong route 23 0.2 32 0.1 73.9 26.1
11
MEQI REPORTS
Medications Involved in Error
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Medications
Warfarin 786 5.4 1,890 3.1 69.1 30.9
Insulin 671 4.6 2,375 3.8 76.0 24.0
Oxycodone 466 3.2 1,212 2.0 90.8 9.2
Hydrocodone 446 3.1 1,198 1.9 93.3 6.7
Lorazepam 434 3.0 970 1.6 91.9 8.1
Fentanyl 308 2.1 370 0.6 84.1 15.9
Furosemide 302 2.1 1,678 2.7 87.7 12.3
Alprazolam 240 1.7 648 1.0 94.6 5.4
Metoprolol 236 1.6 1,134 1.8 92.4 7.6
Omeprazole 232 1.6 941 1.5 98.7 1.3
Clonazepam 216 1.5 546 0.9 92.6 7.4
Aspirin 207 1.4 1,855 3.0 97.1 2.9
Potassium chloride 192 1.3 955 1.5 93.2 6.8
Levothyroxine 189 1.3 811 1.3 94.2 5.8
Polyethylene glycol 154 1.1 838 1.4 97.4 2.6
Zolpidem 153 1.1 653 1.1 89.5 10.5
Docusate 146 1.0 821 1.3 98.6 1.4
Morphine 144 1.0 490 0.8 86.8 13.2
Gabapentin 142 1.0 760 1.2 97.9 2.1
Mirtazapine 139 1.0 786 1.3 98.6 1.4
Quetiapine 128 0.9 960 1.6 93.0 7.0
Acetaminophen 127 0.9 506 0.8 95.3 4.7
Lisinopril 125 0.9 611 1.0 91.2 8.8
Simvastatin 120 0.8 567 0.9 98.3 1.7
Mmultivitamin 119 0.8 420 0.7 97.5 2.5
Calcium-vitamin D 117 0.8 681 1.1 99.1 0.9
Enoxaparin 108 0.7 329 0.5 84.3 15.7
Tramadol 104 0.7 467 0.8 92.3 7.7
Clonidine 103 0.7 225 0.4 79.6 20.4
Other drug 7,672 52.8 36,033 58.3 93.6 6.7
12
Medications Involved in Error
There were 654 diferent medications reported in errors for FY2012. 566 of these were reported in more
than one error, and 309 in more than 5 errors. Warfarin (786) is the most common medication involved
in errors, followed by insulin (671), oxycodone combinations (466), hydrocodone combinations (446),
lorazepam (434) and fentanyl (308). Many of these common medications in NC nursing home errors
also are consistently included on lists of dangerous medications and on lists of medications that are
cautioned for use in the elderly. Aside from warfarin and insulin, the other most common medications
are controlled substances. The 29 most common types of medications involved in error incidents in NC
are listed in the table. They each have over 100 errors and together account for nearly one half of all
error incidents. Within this list there
are three medications that are more
than twice as likely to have serious
outcomes: warfarin (30.9% serious),
insulin (24% serious), and clonidine
(20.4% serious).
Therapeutic Class
Medications involved in error have
been grouped by the therapeutic
class codes found in the Multum
Cerner medication database. The
medications are grouped into
seventeen diferent classes. Over one
quarter (27.6%) of the errors (4,012)
are classified as central nervous
system agents. Central nervous
system agents include narcotics,
analgesics, anticonvulsants and
sedatives. Other therapeutic classes
with over 1000 errors each are
cardiovascular agents (10.7%),
metabolic agents (includes the
various insulin products) (8.6%),
nutritional products (8.5%),
coagulation modifiers (8.3%),
and gastrointestinal agents
(7.7%). Coagulation modifiers
(anticoagulants), which include
warfarin, enoxaparin, and heparin,
is the class with the most serious
outcomes – with 22.2% of errors
(268 serious errors) in this class
leading to an error with an outcome
category 4-9.
MEQI REPORTS
Medications Involved in Error by
Therapeutic Class Name
FY 2012
Error
Incidents
% Minor % Serious %
All Errors 14,526 100.0 91.0 9.0
Therapeutic Class
central nervous
system agents
4,012 27.6 92.0 8.0
cardiovascular agents 1,551 10.7 90.0 10.0
metabolic agents 1,256 8.6 85.4 14.6
nutritional products 1,240 8.5 94.8 5.2
coagulation modifiers 1,207 8.3 77.4 22.6
gastrointestinal
agents
1,116 7.7 97.4 2.6
anti-infectives 980 6.7 88.8 11.2
psychotherapeutic
agents
916 6.3 94.0 6.0
topical agents 615 4.2 95.9 4.1
miscellaneous agents 448 3.1 93.5 6.5
respiratory agents 433 3.0 96.5 3.5
hormones/hormone
modifiers
364 2.5 92.9 7.1
biologicals 95 0.7 88.4 11.6
genitourinary tract
agents
90 0.6 95.6 4.4
antineoplastics 87 0.6 92.0 8.0
alternative medicines 77 0.5 98.7 1.3
immunologic agents 37 0.3 83.8 16.2
radiologic agents 2 0.0 100.0 0
13
Efects of Errors on Patients
In this section, nursing homes are asked to report the efect of the error on the patient and more than
one efect can be noted. As in prior years most errors were reported as having no injury or efect. For FY
2012, 13,572 or 93.0% of reported errors had no injury or physical efect. Only 1024 of the errors reported
noted a physical efect of the error. The most common reported efect, with 341 errors (33% of error
efects), is inadequate efect of medication. This is primarily related to dose omission errors, where the
resident did not receive their medication. Other efects that were commonly reported include: increase/
decrease in PT/INR (175) which is a test used to look at the efect of anticoagulants (such as warfarin)
and blood cloting, increase or
decrease in blood sugar (97)
often found in conjunction
with insulin use, pain (70),
somnolence/lethargy (55), and
change in blood pressure(55).
Cause of Errors
The most commonly reported
cause of error this year was
‘staf did not follow policies
and procedures’, with 60.3% of
errors reporting this as a cause.
Other common causes include
transcription error (21.7%),
distractions on floor (4.9%),
poor communication (2.9%), and
medication unavailable (1.8%).
These are the same five most
common causes as in prior years.
Each year there are diferent
causes involved in serious error,
with very litle overlap from
year to year. In 2012 there are
four causes of errors that are
more than twice as likely to have
serious outcomes; however,
some of these are indicated in
only a small number of errors;
poor communication (22.1%
serious), too much workload/
overtime (20.8 % serious), use of
abbreviations (30% serious), and
pharmacy delivered to wrong
facility (33.3% serious).
MEQI REPORTS
Efects of Error on Patient
FY 2012
Error
Incidents
% Repeat
Errors
%
All Errors 14,596 100.0 62,150 100.0
Efects
no injury or efect 13,572 93.0 57,163 92.0
Inadequate efect 341 2.3 1,901 3.1
PT/INR increase/decrease 175 1.2 471 0.8
Change in blood sugar 97 0.7 481 0.8
Pain 70 0.5 166 0.3
Somnolence/lethargy 55 0.4 181 0.3
Change in blood pressure 55 0.4 218 0.4
Excessive side efects 34 0.2 143 0.2
Agitation/anxiety 30 0.2 179 0.3
Sleep change 30 0.2 95 0.2
Mood change 24 0.2 293 0.5
Constipation/Diarrhea 18 0.1 112 0.2
Nausea/Vomiting 15 0.1 71 0.1
Weight change 14 0.1 142 0.2
Edema 14 0.1 129 0.2
Cognitive change 11 0.1 80 0.1
Respiratory distress 9 0.1 16 0.0
Allergic reaction 7 0.0 12 0.0
Fall 6 0.0 51 0.1
Appetite change 4 0.0 81 0.1
Wound/fracture/bruise 4 0.0 8 0.0
Seizure 4 0.0 72 0.1
Headache 3 0.0 4 0.0
Visual disturbance 2 0.0 4 0.0
GI bleed 2 0.0 77 0.1
14
Phase Where Errors Occur
Nursing homes also report in which of the five process phases the medication error initially occurred.
Most errors reported are those that occur within the nursing home itself, with 57.1% in medication
administration, 37% in the documentation phase, and 3.4% during the monitoring phase. The largest
percentage of repeat errors continues to be those related to documentation; these account for over 63%
of repeat errors. This year we saw an increase of serious errors in the monitoring phase–this is possibly
related to the high number of errors in warfarin and insulin, both of which cause more serious errors
and require a high level of monitoring. In 2012 only 0.5 % of the errors were reported in the prescribing
phase (74 errors) and 1.9% in dispensing (283 errors). These two types of errors are usually reported in
our system only if discovered or identified by nursing home staf. There was again a noticeable decrease
in dispensing errors reported this year, from 4.8% of total in 2010 to 3.0% in 2011 and to 1.9% in 2012.
MEQI REPORTS
Cause of Error
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 16,931 100.0 75,036 100.0 89.7 10.3
Primary Personnel
Staf did not follow policies 10,210 60.3 33,101 44.1 91.7 8.3
Transcription error 3,666 21.7 30,199 40.2 88.5 11.5
Distractions on floor 836 4.9 2,719 3.6 84.8 15.2
Poor Communication 485 2.9 2,113 2.8 77.9 22.1
Med unavailable 306 1.8 954 1.3 89.2 10.8
Pharmacy dispensing 243 1.4 1,548 2.1 89.3 10.7
Name confusion 205 1.2 644 0.9 86.8 13.2
Current policies faulty 143 0.8 490 0.7 82.5 17.5
Inadequate info 127 0.8 710 0.9 88.2 11.8
Improper training 121 0.7 276 0.4 84.3 15.7
Package design 108 0.6 207 0.3 82.4 17.6
Pharm delivered wrong med 90 0.5 495 0.7 90.0 10.0
Shift change 82 0.5 166 0.2 85.4 14.6
Illegible handwriting 75 0.4 751 1.0 86.7 13.3
Product label 71 0.4 314 0.4 90.1 9.9
Too much workload/overtime 48 0.3 137 0.2 79.2 20.8
Exhaustion 40 0.2 73 0.1 82.5 17.5
Emergency on floor 36 0.2 46 0.1 80.6 19.4
Poor working conditions 15 0.1 15 0.0 86.7 13.3
Use of Abbreviations 10 0.1 42 0.1 70.0 30.0
Pharmacy closed 8 0.0 16 0.0 87.5 12.5
Pharm delivered to wrong facility 6 0.0 20 0.0 66.7 33.3
15
Personnel Involved in Error
Nurses, both RN and LPN, are primarily responsible for
the delivery of medications in nursing homes. In 2012
LPNs, who are the most common caregivers and were
involved in most medication error incident reports
(69.4%), while RNs were involved in 22.6%. Medication
aides were involved in 4.1% of errors. Pharmacists or
pharmacy staf account for another 2.9% of errors
(a reduction from 5.1% in 2010, then 3.5% in 2011).
In 161 errors (1.1%) the primary personnel involved
in the error was listed as a temporary, contract, or
agency staf. Students/trainees or patient/caregiver
errors are often more serious, but account for very
few errors.
MEQI REPORTS
Phase of Error Occurence
FY 2011
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Phase
Administering 8,296 57.1 19,372 31.4 90.9 9.1
Documenting 5,377 37.0 39,000 63.2 91.9 8.1
Monitoring 496 3.4 855 1.4 81.5 18.5
Dispensing 283 1.9 1,825 3.0 89.4 10.6
Prescribing 74 0.5 678 1.1 93.2 6.8
MEQI Reports
Phase of Error Occurrence
FY 2012
1.95% 0.51%
5377
37.02%
8296
57.11%
3.41%
Errors
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Medication Phase
Administering Documenting Monitoring Dispensing Prescribing
MEQI Reports
Number of Errors for Each Personnel Category
FY 2012
PCT.
69.45
22.59
4.09
0.47
2.86
0.03
0.18
0.05
0.18
0.10
Personnel
Physician Assistant
Patient or Caregiver
Nurse Aide/CNA
Student or Trainee
Nurse Practitioner
Physician
Pharmacist/Pharm Tech
Medication Aide
RN
LPN
Number of Errors
0 2000 4000 6000 8000 10000 12000
MEQI Reports
Errors by Work Shift
FY 2012
7540
51.91%
5759
39.65%
1227
8.45%
Percent
0
10
20
30
40
50
60
Shift
7am to 3pm 3pm to 11pm 11pm to 7am
16
Work Shift
Each error is also assigned to the work shift in which the error occurred, or if unknown, the shift
where the error was identified. About half (51.9%) of all errors continue to be noted as day shift
incidents (7am to 3pm). Another 39.6% were noted as the afternoon/evening shift incidents
(3pm to 11pm). A smaller number of errors (8.4%) were noted as nightshift incidents (11pm to
7am). Since most medications are administered during the day and evening shifts, more errors
would be anticipated during these shifts compared to the night shift. For FY 2012 there was litle
variation in serious outcomes among shifts.
MEQI REPORTS
Work Shift of Error Occurrence
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Work Shift
7am to 3pm 7,540 51.9 38,372 62.2 91.3 8.7
3pm to 11pm 5,759 39.6 20,318 32.9 90.7 9.3
11pm to 7am 1,227 8.4 3,040 4.9 89.8 10.2
MEQI REPORTS
Personnel
FY 2012
Error
Incidents
% Repeat
Errors
% Minor % Serious %
All Errors 14,526 100.0 61,730 100.0 91.0 9.0
Primary Personnel
LPN 10,088 69.4 41,976 68.0 91.5 8.5
RN 3,281 22.6 13,577 22.0 89.8 10.2
Medication Aide 594 4.1 2,076 3.4 90.2 9.8
Pharmacist/Pharm Tech 416 2.9 2,688 4.4 89.9 10.1
Physician 68 0.5 787 1.3 94.1 5.9
Nurse Practitioner 26 0.2 155 0.3 92.3 7.7
Student or Trainee 26 0.2 51 0.1 50.0 50.0
Nurse Aide/CNA 15 0.1 292 0.5 93.3 6.7
Patient or Caregiver 7 0.0 19 0.0 71.4 28.6
Physician Assistant 5 0.0 109 0.2 100.0 0.0
Primary Personnel involved was temporary or contract staf at time of error
No 14,243 98.1 59,648 96.6 90.9 9.1
Yes 161 1.1 574 0.9 88.2 11.8
Unknown 122 0.8 1,508 2.4 95.1 4.9
17
Conclusion
The MEQI project has now collected medication errors from nursing homes for nine years. This is
the final year of data collection for the project. What began with a simple online year end form
has expanded to include an individual error entry system that could be used year-round. Over
time we added site specific summary data reports, graphic reports, and a toolkit, all to enhance
the user experience. Many of the 400 nursing homes participated with us in making these
changes, responding to surveys and participating in pilot tests and key informant interviews to
give us feedback and improve the system.
Most errors reported to the MEQI system over time have not harmed the patient, and have
resulted in no injury or efect on the patient. It is a small number of errors, around 9% that are
an area for concern, and a smaller percentage yet, about 1% that lead to what most national
definitions would consider to be patient harm. The goal of most nursing homes should be to
address system issues that lead to the repetition of the most harmful medication errors. It is
also clear that facilities have varying ideas about what an error is, and interpret reportable error
guidelines diferently from one another. Some homes consistently report under 20 errors per year
(in some cases 0), and some report over 1000 errors per year. This understanding of reporting
does not, as far as we can tell, relate to the quality of any particular nursing home, but rather
to the leadership staf and how they interpret the guidance provided. Error report numbers on
a facility level are not useful for determining facility quality, but on a larger scale can provide
valuable information on specific medications, and types of error for targeting interventions.
Medication Error Quality Initiative
Improving Medication Safety in
North Carolina Nursing Homes
MEQRX I